POTOMAC UROLOGY CENTER

2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201

Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Patient Registration
Name: SSN: _____________________Sex: M / F/ Transgender
Last First MI

Home Address:
Street Address Apt No. City State Zip Code

Date of Birth: ____________________ Home Phone: ____________________ Cell Phone:

Employer/School: Full-time / Part-time: _______________________________ Email Address: ___________________

Employer/School Address:
Street Address City State Zip Code

Work Number: ________________________ Marital Status:

Whom may we thank for referring you today?


Pharmacy Name & Location Pharmacy Phone Primary Care Physician PCP Phone
Emergency Contact
Name: Relationship:

Home Phone: ______________ Mobile Phone: ____________ Work Phone:
I nsurance I nformation

______________________________ _________________________________
Primary Insurance Secondary Insurance
______________________________ _________________________________
ID Number ID Number
______________________________ _________________________________
Group Number Group Number
______________________________ _________________________________
Subscribers Name/Relation Subscribers Name/Relation
______________________________ _________________________________
Subscribers Social Security Number Subscribers Social Security Number
______________________________ _________________________________
Subscribers Date of Birth Subscribers Date of Birth
______________________________ _________________________________
Subscribers Employer Subscribers Employer
______________________________ _________________________________
Subscribers Address if different than yours Subscribers Address if different than yours
I, __________________________________ hereby assign, authorize and request the payment from my insurance
carrier be paid directly to Potomac Urology Center, PC.
I certify that the information reported is correct, current, valid and complete. I hereby authorize the release of any
information for this or any other related claim to my insurance carrier.
I also realize that insurance coverage does not guarantee payment for services performed and all charges are my
responsibility, with payment in full due within 90 days from the date of service. I will contact my insurance carrier in 2
months, if my claims are still unpaid. I also agree that if there are any balances due or my claim is disputed or denied by my
insurance, I will pay in full immediately upon notification from them.
I understand that the prices are subject to change.
In the event that my account is placed in the hands of a collection agency and/or an attorney, I agree to pay all costs related to
the collection, which could be up to 33 1/3% additional to the balance due.
I understand that I will be charged $50.00 for all returned checks.


Patient/Parent Signature Printed Name DOB Date
POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com

Name: _______________________________________ Date of Birth:
Last First MI

RACE: CHECK ONE ETHNICITY: CHECK ONE

NATIVE HAWAIIAN OR OTHER PACIFIC HISPANIC OR LATINO
BLACK OR AFRICAN AMERICAN NOT HISPANIC OR LATINO
WHITE REFUSED TO REPORT
HISPANIC
OTHER RACE
OTHER PACIFIC ISLANDER
UNREPORTED/REFUSED TO REPORT

LANGUAGE: CHECK ONE
ENGLISH
SPANISH
RUSSIAN
INDIAN (INCLUDES HINDI & TAMIL)
OTHER

Health Questionnaire

Reason for Todays Visit:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Current Medical Conditions:





Past Surgical History:
__________________________________________________________________________________________
__________________________________________________________________________________________
_

Are you currently taking medications? Yes No
Are you taking Aspirin, Coumadin, Blood Thinners? Yes No
Please list medications:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Do you have any allergies to medications?
__________________________________________________________________________________________


I hereby consent to treatment by Potomac Urology Center, PC. I hereby authorize Potomac Urology
Center, PC to obtain my prescription history and any additional information they may request in regards
to my Medication History

Signature of Patient (legally responsible party) Date
POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
PAST MEDICAL, FAMILY AND SOCIAL HISTORY

Are you or a blood relative having problems (now or in the past) with any of the following?
No Yes If yes, please check all boxes that apply.
FAMILY
YOU MEMBER
Anemia
Arthritis
Asthma
Cancer
Type of Cancer:
Depression
Diabetes
GERD/Acid Reflux
Gout (high uric acid)
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Stones
Liver Disease
Mitral Valve Prolapse
Osteoporosis
Rheumatic Fever
Thyroid Problems
Toxic Exposure
Tuberculosis
Other/Explain:
Have you had surgery on any of the following? If yes, please check all boxes that apply.

INCLUDE SURGERY DATE
YES NO
Appendix
Back
Bladder
Breast
Colon
Gallbladder
Heart Bypass
Heart Valve
Hernia
Incontinence
Kidney
Lung
Thyroid
Urethra
Total Joint Replacement
Right: Hip Knee Shoulder
Left: Hip Knee Shoulder


Patient/Parent Signature Printed Name DOB Date
POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com

SURGERIES CONTINUED:
***WOMEN ONLY YES NO
Hysterectomy
Pelvic Laparoscopy
Could you be pregnant?
Number of Pregnancies: Vaginal Cesarean

***MEN ONLY
Prostate
Testicle
Vasectomy
Have you ever had MRSA?
Positive Mantoux/PPD?
BOTH MEN & WOMEN
Do you or did you smoke? Yes No
If yes, how many packs per day? _____ How many years? ______When did you quit? _______
Do you drink alcohol? Yes No If yes, how much? _______________
Are you on a special diet? Yes No If yes, explain? __________________
Are you Employed? Yes No Retired Occupation? _____________
Do you have children? Yes No Year(s) of Birth? __________
Do you have any problems NOW related to the following systems? Please circle Yes or No.
Constitutional Symptoms Cardiovascular Respiratory
Fever Yes No Chest Pain Yes No Wheezing Yes No
Chills Yes No Varicose veins Yes No Frequent cough Yes No
Headache Yes No High/Low blood Shortness of
Weight Gain/Loss Yes No pressure breathe Yes No
Other: ________________ Other: ________________ Other: ________________
Endocrine Ear/Nose/Throat/Mouth Gynecologic
Excessive thirst Yes No Ear Infection Yes No Heavy periods Yes No
Too hot/Cold Yes No Sore throat Yes No Irregular periods Yes No
Tired/Sluggish Yes No Sinus problems Yes No Menopause Yes No
Other: _______________ Other: ________________ If yes, when? ____________
Integumentary Sexual History Hormone therapy Yes No
Skin Rash Yes No Sexually active? Yes No Other: ________________
Boils Yes No Pain with
Persistent rash Yes No intercourse? Yes No Neurological
Other: ________________ Leaking urine Tremors Yes No
with intercourse? Yes No Dizzy Spells Yes No
Gastrointestinal Other: ________________ Numbness Yes No
Abdominal Pain Yes No Hematologic/Lymphatic Headaches Yes No
Nausea/Vomiting Yes No Swollen glands Yes No Other: ________________
Indigestion Yes No Blood clotting
Heartburn Yes No Problem? Yes No Eyes
Constipation Yes No Pulmonary Blurred Vision Yes No
IBS Yes No Embolism Yes No Boils Yes No
Diarrhea Yes No Anemia Yes No Persistent rash Yes No
Rectal Bleed Yes No HIV/AIDS Yes No Other: _______________
Other: ________________ Other: ________________


Patient/Parent Signature Printed Name DOB Date


POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Billing Policies

ASSIGNMENT OF BENEFITS: I hereby assign to you Potomac Urology Center, PC, all medical benefits to
what I am entitled, including Medicare or any other insurance plan. I hereby authorize said assignee, Potomac
Urology Center, PC to release all information to secure payment, including appeals on my behalf to the Insurance
Commissioner. I also authorize my insurance company to release any/all information to Potomac Urology Center,
PC that may be necessary to secure payment. I also understand that I am financially responsible for all charges my
insurance company states are patient responsibility, including any deductibles and copayments and that payments
are due at the time services are rendered. If Potomac Urology Center, PC does not participate with my insurance
company, I understand that I am responsible for all charges not paid by my insurance. I also understand that if I
am signing on behalf of my minor dependent, that I am responsible for all charges rendered patient responsibility.

I understand that in the event my account becomes past due (over 90 days) and all attempts to arrange
payment have failed, my account will be turned over to a collection agency and/or attorney. I also
understand that I will be responsible for all collection agency fees (33 1/3%) of total past due amount and
all other costs expended to the collection said amount.

NO SHOW FEE: It is our policy to require appointment cancellations no later than 48 hours in advance in order
to avoid a no show charge. Effective January 2, 2011 failure to notify Potomac Urology Center, PC within this time
limit or failure to show up for scheduled appointment will result in a $50 Office Visit fee, $200 CMG Testing fee,
$100 Cystoscopy fee, $500 Hospital Surgery fee, $100 Surgical Procedures in Office fee & $250 Vasectomy fee to
your account. This charge cannot be billed to any insurance company, IT IS YOUR RESPONSIBILITY. You
will receive a bill for this and payment is expected prior to your next appointment.

HMO PATIENTS: Potomac Urology Center, PC is a specialty medical practice. IT IS YOUR
RESPONSIBILITY TO OBTAIN REQUIRED REFERRALS FROM YOUR PRIMARY CARE
PHYSICIAN PRIOR TO EACH VISIT. For return patients, if you are uncertain whether or not you have a
valid referral on file, please call the office 48 hours prior to your visit to clarify the issue.
Appointments will be rescheduled if required referrals are not presented prior to or on the scheduled appointment
day.

PRIVACY NOTICE: My signature below confirms that I was given the opportunity to read, understand and ask
questions about Potomac Urology Center, PC Notice of Privacy Practices exhibited in the waiting room (copy given
upon request). I hereby authorize Potomac Urology Center, PC to release any information pertaining to my health
care, test results, billing and/or accounting information to the following person(s) or agencies. I understand that I
have a right to inspect and receive a copy of the disclosed material at a cost of $10 administration fee, $0.50 per
page for the first 50 pages and $0.25 per page after 50 pages. These charges are in accordance with the VA
CODE A01-4V13. I also understand that Potomac Urology Center, PC charges $25 to complete any additional
forms.
Myself My Significant Other Leave information on my voice mail
Others (specify): _____________________________________________
_____________________________________________
_____________________________________________
I certify that I understand and agree with the above policies. I also certify that the information I have given is
correct to the best of my knowledge.



Patient/Parent Signature Printed Name DOB Date